Lung recruitment maneuver: Difference between revisions
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**Refer to your RT for hospital protocol | **Refer to your RT for hospital protocol | ||
**Proning patient is considered a recruitment maneuver | **Proning patient is considered a recruitment maneuver | ||
*'''Indication:''' severe ARDS < 1 wk, before onset of fibro-proliferation<ref>Habashi, NM et al. New Directions in Ventilatory Management from: Advanced Therapy in Thoracic Surgery Chapter 3. pp 24-35. Franco KL, Putnam JB. 1998.</ref><ref>Richards G et al. Oct 2006 last updated. http://www.anaesthetist.com/icu/organs/lung/recruit/Findex.htm.</ref> | *'''Indication:''' severe [[ARDS]] < 1 wk, before onset of fibro-proliferation<ref>Habashi, NM et al. New Directions in Ventilatory Management from: Advanced Therapy in Thoracic Surgery Chapter 3. pp 24-35. Franco KL, Putnam JB. 1998.</ref><ref>Richards G et al. Oct 2006 last updated. http://www.anaesthetist.com/icu/organs/lung/recruit/Findex.htm.</ref> | ||
*Biotrauma and cytokine release occur due to: | *Goals to recruit alveoli, maintain with PEEP at the derecruitment point, prevent cyclic collapse/VILI | ||
**Improving hypoxemia via recruitment | |||
**Decrease [[ventilator-induced lung injury]] (VILI) | |||
*Derecruitment of alveoli occurs due to<ref>Nickson C. Lung Recruitment Maneuvers. 21 Sept 2014. http://lifeinthefastlane.com/ccc/recruitment-manoeuvres-in-ards/</ref>: | |||
**Standard low TV ventilation in ARDS | |||
**Insufficient PEEP | |||
**High FiO2 absorptive atelectasis | |||
*Biotrauma and cytokine release (VILI) occur due to: | |||
**Dependent areas of airway are collapsed throughout TVs | **Dependent areas of airway are collapsed throughout TVs | ||
**Cyclic collapse causes shear injury atelectrauma with each breath | **Cyclic collapse causes shear injury atelectrauma with each breath | ||
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***TVs > 6 cc/kg | ***TVs > 6 cc/kg | ||
***Pplat > 30-35 cmH2O | ***Pplat > 30-35 cmH2O | ||
==Risks== | ==Risks== | ||
*May only be temporary benefit | *May only be temporary benefit | ||
*Hemodynamic instability with drop off in preload | *[[shock|Hemodynamic instability]] with drop off in preload | ||
*CO2 retention | *[[hypercapnia|CO2 retention]] | ||
*May worsen oxygenation by shunting blood to poorly aerated lung (opposing physiological hypoxic pulmonary vasoconstriction) | *May worsen oxygenation by shunting blood to poorly aerated lung (opposing physiological hypoxic pulmonary vasoconstriction) | ||
*May worsen [[ventilator-induced lung injury]] with volutrauma/barotrauma | *May worsen [[ventilator-induced lung injury]] with volutrauma/barotrauma | ||
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*Contraindications | *Contraindications | ||
**Unstable BP | **Unstable BP | ||
** | **[[pneumothorax]] or high risk of pneumothorax (blebs, necrotising pneumonia) | ||
**ARDS > 1 wk (relative contraindication) | **[[ARDS]] > 1 wk (relative contraindication) | ||
==Procedure<ref>Medical College of Georgia. Open Lung Tool Procedure Protocol. Updated 2014.</ref>== | ==Procedure<ref>Medical College of Georgia. Open Lung Tool Procedure Protocol. Updated 2014.</ref>== | ||
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**HR < 60 bpm | **HR < 60 bpm | ||
**HR > 140 bpm | **HR > 140 bpm | ||
**New dysrhythmia on monitor (may indicate significant respiratory acid-base shift) | **New [[dysrhythmia]] on monitor (may indicate significant respiratory acid-base shift) | ||
**SBP < 80 mmHg | **SBP < 80 mmHg | ||
**Sustained SaO2 < 85% | **Sustained SaO2 < 85% | ||
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*May require increased sedation or paralysis | *May require increased sedation or paralysis | ||
*Optimize preload (maneuver decreases preload) | *Optimize preload (maneuver decreases preload) | ||
*Maintain a very reliable, good waveform | *Maintain a very reliable, good waveform SpO2 (that matches ABG SaO2) | ||
*[[ | *14 ga needles x2 in case of [[pneumothorax]] | ||
*Record baseline vital signs and initial ventilator settings | |||
**I:E to 1:1 | **I:E to 1:1 | ||
**Adjust FiO2 to SaO2 90-92% | **Adjust FiO2 to SaO2 90-92% | ||
**Take note of dynamic compliance levels | **Take note of dynamic compliance levels | ||
** | **[[Pressure control ventilation]] using current rate, PEEP, FiO2 before maneuver | ||
***Adjust PC level above PEEP to start at TV of 6 cc/kg for 2 minutes | |||
***Then set PC level (Pi) to 15 cmH2O above PEEP and maintain this difference throughout initial recruitment | |||
***Adjust RR to maintain appropriate minute ventilation | |||
===Increasing PEEP=== | ===Increasing PEEP=== | ||
*Increase PEEP to 15 cmH2O | *Increase PEEP to 15 cmH2O | ||
*Set PC level to 15 cmH2O above PEEP | *Set PC level to 15 cmH2O above PEEP | ||
**Maintain this difference between PEEP and PC level (Pi) | **Maintain this difference between PEEP and PC level (Pi) | ||
**Increase q2 minutes PEEP to 20 | **Increase q2 minutes PEEP to 20 → 30 → 40 cmH2O | ||
***Pi will reach 55 cmH2O | ***Pi will reach 55 cmH2O | ||
***Note maximum SaO2 obtained | ***Note maximum SaO2 obtained | ||
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===Reducing PEEP=== | ===Reducing PEEP=== | ||
*Reduce q3 minutes PEEP to 25 | *Reduce q3 minutes PEEP to 25 → 22.5 → 20 → 17.5 cmH2O | ||
*Remember that SpO2 monitor | *Remember that SpO2 monitor displays results up to 1-2 min after clinical change | ||
*Until: | *Until: | ||
**Decrease in SaO2 of 1% from maximum SaO2 observed, which is the '''derecruitment point''' | **Decrease in SaO2 of 1% from maximum SaO2 observed, which is the '''derecruitment point''' | ||
**OR minimum of 15 cmH2O PEEP reached | **'''OR''' minimum of 15 cmH2O PEEP reached | ||
===Re-recruitment=== | ===Re-recruitment=== | ||
*Increase PEEP step-wise q2 minutes to 40 cmH2O again | *Increase PEEP step-wise q2 minutes to 40 cmH2O again | ||
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*Return to PEEP level 2-4 cmH2O above '''decruitment point''' | *Return to PEEP level 2-4 cmH2O above '''decruitment point''' | ||
*Adjust TV 4-6 cc/kg and plateau pressures < 30 cmH2O | *Adjust TV 4-6 cc/kg and plateau pressures < 30 cmH2O | ||
*Tolerate permissive | *Tolerate permissive hypercapnia if pH > 7.15 | ||
*May increase RR up to maximum of 38 bpm | *May increase RR up to maximum of 38 bpm | ||
==Adjuncts== | ==Adjuncts== | ||
*[[Inhaled nitric oxide]] ( | *[[Inhaled nitric oxide]] (iNO) | ||
*[[ | *[[Epoprostenol (prostacyclin)]] (Flolan) | ||
*[[ | *[[Extracorporeal membrane oxygenation]] | ||
* | *[[High frequency oscillation ventilation]] (HFOV) | ||
==See Also== | ==See Also== | ||
*[[ | *[[Acute respiratory distress syndrome]] | ||
*[[Mechanical ventilation | *[[Mechanical ventilation (main)]] | ||
*[[Ventilator associated lung injury]] | |||
*[[Ventilator | |||
==References== | ==References== | ||
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[[Category:Pulmonary]] | [[Category:Pulmonary]] | ||
[[Category:Critical Care]] | [[Category:Critical Care]] | ||
[[Category:Procedures]] |
Latest revision as of 15:33, 27 September 2019
Background
- Controversial in terms of safety and efficacy
- No mortality/morbidity outcome benefits[1]
- May be of more benefit to extra-pulmonary ARDS than to pulmonary ARDS
- Multiple methods reported
- Below is only one method (Starcase Recruitment Maneuver)
- Refer to your RT for hospital protocol
- Proning patient is considered a recruitment maneuver
- Indication: severe ARDS < 1 wk, before onset of fibro-proliferation[2][3]
- Goals to recruit alveoli, maintain with PEEP at the derecruitment point, prevent cyclic collapse/VILI
- Improving hypoxemia via recruitment
- Decrease ventilator-induced lung injury (VILI)
- Derecruitment of alveoli occurs due to[4]:
- Standard low TV ventilation in ARDS
- Insufficient PEEP
- High FiO2 absorptive atelectasis
- Biotrauma and cytokine release (VILI) occur due to:
- Dependent areas of airway are collapsed throughout TVs
- Cyclic collapse causes shear injury atelectrauma with each breath
- Least dependent areas inflated throughout TVs are also easily hyperinflated causing volutrauma and barotrauma, especially in:
- TVs > 6 cc/kg
- Pplat > 30-35 cmH2O
Risks
- May only be temporary benefit
- Hemodynamic instability with drop off in preload
- CO2 retention
- May worsen oxygenation by shunting blood to poorly aerated lung (opposing physiological hypoxic pulmonary vasoconstriction)
- May worsen ventilator-induced lung injury with volutrauma/barotrauma
- Pneumothorax
- Contraindications
- Unstable BP
- pneumothorax or high risk of pneumothorax (blebs, necrotising pneumonia)
- ARDS > 1 wk (relative contraindication)
Procedure[5]
- Goal is to find the derecruitment point
Failure
- Before attempting, know when the maneuver should be stopped
- Stop and return to baseline PCV settings if:
- HR < 60 bpm
- HR > 140 bpm
- New dysrhythmia on monitor (may indicate significant respiratory acid-base shift)
- SBP < 80 mmHg
- Sustained SaO2 < 85%
- Drop in dynamic compliance (pneumothorax)
Preparation
- May require increased sedation or paralysis
- Optimize preload (maneuver decreases preload)
- Maintain a very reliable, good waveform SpO2 (that matches ABG SaO2)
- 14 ga needles x2 in case of pneumothorax
- Record baseline vital signs and initial ventilator settings
- I:E to 1:1
- Adjust FiO2 to SaO2 90-92%
- Take note of dynamic compliance levels
- Pressure control ventilation using current rate, PEEP, FiO2 before maneuver
- Adjust PC level above PEEP to start at TV of 6 cc/kg for 2 minutes
- Then set PC level (Pi) to 15 cmH2O above PEEP and maintain this difference throughout initial recruitment
- Adjust RR to maintain appropriate minute ventilation
Increasing PEEP
- Increase PEEP to 15 cmH2O
- Set PC level to 15 cmH2O above PEEP
- Maintain this difference between PEEP and PC level (Pi)
- Increase q2 minutes PEEP to 20 → 30 → 40 cmH2O
- Pi will reach 55 cmH2O
- Note maximum SaO2 obtained
- Treat SBP drops as necessary, but halt procedure if > 20% SBP drop despite pressors/fluids
- Increase PIP as necessary
- Maintain minute ventilation
- Reduce RR before PIP increase since TV will increase
Reducing PEEP
- Reduce q3 minutes PEEP to 25 → 22.5 → 20 → 17.5 cmH2O
- Remember that SpO2 monitor displays results up to 1-2 min after clinical change
- Until:
- Decrease in SaO2 of 1% from maximum SaO2 observed, which is the derecruitment point
- OR minimum of 15 cmH2O PEEP reached
Re-recruitment
- Increase PEEP step-wise q2 minutes to 40 cmH2O again
- Maintain PEEP at 40 cmH2O for 2 minutes
- Return to PEEP level 2-4 cmH2O above decruitment point
- Adjust TV 4-6 cc/kg and plateau pressures < 30 cmH2O
- Tolerate permissive hypercapnia if pH > 7.15
- May increase RR up to maximum of 38 bpm
Adjuncts
- Inhaled nitric oxide (iNO)
- Epoprostenol (prostacyclin) (Flolan)
- Extracorporeal membrane oxygenation
- High frequency oscillation ventilation (HFOV)
See Also
References
- ↑ Guerin C et al. Efficacy and safety of recruitment maneuvers in acute respiratory distress syndrome. Ann Intensive Care. 2011; 1: 9.
- ↑ Habashi, NM et al. New Directions in Ventilatory Management from: Advanced Therapy in Thoracic Surgery Chapter 3. pp 24-35. Franco KL, Putnam JB. 1998.
- ↑ Richards G et al. Oct 2006 last updated. http://www.anaesthetist.com/icu/organs/lung/recruit/Findex.htm.
- ↑ Nickson C. Lung Recruitment Maneuvers. 21 Sept 2014. http://lifeinthefastlane.com/ccc/recruitment-manoeuvres-in-ards/
- ↑ Medical College of Georgia. Open Lung Tool Procedure Protocol. Updated 2014.